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Transdural anastomosis (TA) from the middle meningeal arteries (MMAs) to the brain is important in maintaining cerebral blood flow in patients with Moyamoya disease. A 16-year-old adolescent girl presented with a transient ischemic attack. Preoperative cerebral angiography revealed TA from the MMA. During surgery, the MMA was exposed on the dural surface directly under the burr hole. Measurement of flow velocity in the MMA with an ultrasonic blood flowmeter revealed increased diastolic flow velocity. As the MMA was assumed to contribute to TA, a new burr hole was made to preserve the MMA, and a bone flap was prepared. Direct and indirect bypass surgeries were performed. Electrocoagulation was not applied to the MMA associated with TA, but the artery was compressed with gelfoam containing fibrin glue to achieve hemostasis. Postoperatively, no evidence of cerebral infarction was detected. Determining which of several MMAs exposed in the surgical field is associated with TA can be difficult. However, measurement of flow velocity with an ultrasonic blood flowmeter to confirm increased flow velocity in the diastolic phase is useful for confirming the presence or absence of TA from the extracranial arteries including the MMA.

Middle meningeal arteries with and without transdural anastomosis in Moyamoya disease can be distinguished using intraoperative Doppler sonography